Hypertensive Emergencies:

Tips for Having your blood

pressure taken.
Dont drink coffee or smoke cigarettes for
30 minutes before.
Before test sit for five minutes with back
supported and feet flat on the ground.
Test your arm on a table even with your
heart.
Wear short sleeves so your arm is
exposed.

Tips for having blood pressure

taken.
Go to the bathroom before test. A full
bladder can affect bp reading.
Get 2 readings and average the two of
them.
Ask the Dr. or nurse to tell you the result
in numbers.

Four sized cuffs (minimum adult and large adult cuffs

in room; small adult and thigh quickly available).
Refer to the listed measurements for cuff and bladder.
Note: Manufacturers may have different names for their
various sized cuffs.
Size Name

Cuff Size

Bladder Circumference

Small Adult size

2226 cm

1224 cm

Adult (regular or standard size)

2734 cm

1630 cm

Large Adult size

3444 cm

1636 cm

Thigh size

4552 cm

2042 cm

Blood Pressure Measurement

Procedure
Wall mount sphygmomanometer:
Position the monitor at screener eye level and within one
meter from the screener.

Rationale
Stays in calibration longer and cant be dropped.

Cuff size: Four cuff sizes should ideally be available. At

minimum, an adult and large adult cuff should be
available.
Cuff size with arm and bladder circumferences:

The most common error in blood pressure measurement is

the use of an inappropriate cuff size. Errors over 30 mmHg
can occur if an under-sized cuff is used.
Cuff bladder length should be at least 80 percent of arm
circumference.
Cuff bladder width should be at least 40 percent of arm
circumference.
If cuff is too small = false high (more pressure needed to
occlude artery).
If cuff too large = false low (less pressure needed to
occlude artery).

Small Adult: 22-26 cm, 12x24 cm

Adult (standard): 27-34 cm, 16x30 cm
Large adult: 34-44 cm, 16x36 cm
Thigh: 45x52 cm, 20x42 cm

Eye level in order to make accurate reading.

Comfortable room temperature

Cold can cause peripheral vasoconstriction and decreasing

blood flow, which can cause a false low reading.

Table and chair: Table at a height so that the clients

upper arm is supported and the brachial artery is level
with heart.

Chair arm rests are too low

Office staff escorts client to screening area.

Blood pressure taken with legs dangling or unsupported

Client sits quietly for five minutes before blood

If arm is too low: false high

If arm is too high: false low

back leads to falsely high readings (on average five

mmHg).

pressure check with legs uncrossed, feet flat on the floor,

back supported, and upper arm bare.
Crossing the legs may increase systolic pressures.
Ask why the client is here for a blood pressure check.

In order to provide the appropriate service for the client,

ask:
Are you having symptoms?
Have you been instructed by your health care provider to

have checks?
Other questions?

Cuff Size
Bladder width > 40% of
mid-arm circumference.
Bladder length 80-100%
of arm circumference.

A. Ideal arm circumference

B. Range of acceptable arm
circumferences
C. Bladder length
D. Midline of bladder
E. Bladder width
F. Cuff width

Many outside forces contribute to blood pressure measurement variability.The following is a list of common actions
that result in inaccurae blood pressure readings that can be easily controlled. 3, 4
Cause

Systolic Effect

The cuff is too small (Most common cause of error in clinical practice!) +10-40 mmHg
The cuff is too large (Most common cause of error in clinical practice!) -5-25 mmHg
The artery line is not centered

+4-6 mmHg

The arm is above heart level

+2 mmHg per inch

The arm is below heart level

- 2 mmHg per inch

Patients feet are not flat on the floor

+5-15 mmHg

Patients back is not supported

+5-15 mmHg

Legs crossed

+ 5-8 mmHg

Patient in pain

+10-30 mmHg

Patient talking

+10-15 mmHg

Patient has full bladder

+10-15 mmHg

Patient has difficulty breathing

+5-8 mmHg

Patient doesnt rest 3-5 minutes

White Coat Syndrome

+10-20 mmHg
+11-20 mmHg

Tobacco or Caffeine use

+6-11 mmHg

The cuff is placed over clothing

+/-10-40 mmHg

Aneroid devices that are out of calibration most often read too low.

Oscillometric Devices
Measure mean arterial pressure (MAP) and
calculates SBP and DBP
The algorithms used are proprietary and
NOT standardized
Results can vary widely and they do not
always closely match BP values
obtained by auscultation
These machines must be calibrated
regularly

Manual vs. Automatic

Manual is the gold standard
Oscillometric measurements preferred
in infants and ICU settings ONLY
All high readings should be confirmed
with a manual

Confirming High BPs

Repeat BP in both arms and one leg
(both not usually necessary)
Repeat 3 times to assure accurate
Dx of HTN requires elevated BPs on 3
separate occasions

Disappearance of HTN with

Repeated Measurement

Case Presentations
Definitions
Evaluation
Management

Case 1
51 year old man admitted to an outside
hospital
CC: Sudden onset of left-sided weakness,
severe headache, slurred speech and left
facial droop
BP 260/172
Head CT Scan showed Right basal ganglia
hemorrhage with shift

HPI: Transported by air ambulance to ER.

Intubated en route due to declining mental status

Case 1
PMH - Hypertension - according to wife,
patient was non-adherent with prescribed
medications
Out patient medications and allergies - not
available
Family History +for HTN/CVA

Exam ER - BP 196/130
Positive for Left dense hemiparesis

Case 1
Hospital day 2
Dilated right pupil
Emergent right frontotemporal craniotomy
and evacuation of clot

Subsequent Hospital Course

Difficult to control BP
Pneumonia

Case 1
Renal MRI
Right kidney 8.1 cm with three renal
arteries
Left kidney 12.2 cm with two renal arteries

Question 1

What is the primary reason for

hypertensive emergencies today?
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin

What is the primary reason for

hypertensive emergencies today?
1. Renovascular
Disease
2. Pheochromocytoma
3. Non-adherence to
anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin

10

Hypertensive Emergency
According to the Joint National
Committee on Hypertension Report
Severely elevated blood pressure with
signs and symptoms of acute end organ
damage
Requires hospitalization
Requires parenteral medication

Hypertensive Urgency
Severely elevated blood pressure
without signs and symptoms of acute
end organ damage
Can be managed as an outpatient
Can be managed with oral medications

Hypertensive Emergency
CNS - encephalopathy,

Damage

intracranial hemorrhage,
Grade 3-4 retinopathy

Kidneys - acute kidney

injury, microscopic
hematuria

Vasculature aortic dissection,

eclampsia

Heart - CHF, MI, angina

Epidemiology
Hypertensive emergencies are common
Occur in 1-2% of the hypertensive population
But, 50 million hypertensive Americans
500,000 hypertensive emergencies/year

Parallels the distribution of primary

hypertension
Higher in the elderly and African Americans
Incidence in men 2 times higher than in
women

Epidemiology
Common associations
Previous history of hypertension
Lack of a primary care physician
Non adherence to antihypertensive
regimen
Elicit drug use (cocaine)

Pathophysiology
Sudden increase in
Systemic Vascular
Resistance

BP

Mechanical Stress with

endothelial injury, increased
permeability, Coag/Plt
activation, fibrin deposition

1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory
cytokines

Underlying Etiology?
Unclear, but some candidates

ACE DD genotype
Absence of the and subunit of ENaC
Elevated adrenomedullin levels*
Elevated natriuretic peptide level*
Abnormalities in oxidative stress markers and
endothelial dysfunction*
*Correct after effective BP treatment

Question 2

What is the most common complaint in

hypertensive emergency?
1.
2.
3.
4.
5.

Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis

What is the most common complaint

in hypertensive emergency?
1.
2.
3.
4.
5.

Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis

Clinical Presentation
Variable
Zampaglione et al (Hypertension 27:144, 1996)
14, 209 ER visits in one year period
108 met definition of hypertensive
emergency (0.8%)
Mean Systolic BP 210 + 32
Mean Diastolic BP 130 + 15

Clinical Presentation
Frequency of signs and symptoms
Chest Pain
Dyspnea
Neuro defect
Interestingly.

27%
22%
21%

Headache was only 3% and epistaxis was 0%

in this study

Question 3

Hypertensive emergency is associated

with a threshold BP of
1.
2.
3.
4.
5.

Systolic > 225 mm Hg

Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above

Hypertensive emergency is
associated with a threshold BP of
1.
2.
3.
4.
5.

Systolic > 225 mm Hg

Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above

Threshold BP
There is no specific BP where
hypertensive emergencies occur
But, organ dysfunction is rare with
diastolic BPs < 130 mm Hg
Rate of increase may be more important
Hence, encephalopathy will occur at lower
BPs in pregnancy and in children

Initial Evaluation
Focused history
History of hypertension?
How well is hypertension controlled?
What antihypertensives?
Adherence to antihypertensive regimen?
Last dose of antihypertensive?

Initial Evaluation
Social History
Recreational Drugs
Amphetamines
Cocaine
Phencyclidine

Initial Evaluation
Confirm BP in both arms
Use appropriate sized BP cuff
Cuff that is too small
BP cuffs that are too small falsely elevate
BP measurements in obese patients

Initial Evaluation
Assess for end-organ damage
Vascular Disease
Assess pulses in all extremities
Auscultate over renal arteries for bruits

Cardiopulmonary
Listen for rales (CHF)
Murmurs or gallops

Initial Evaluation
Neurologic Exam
Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures
Lateralizing signs uncommon and suggest
cerebrovascular accident

Retinal Exam
Lost art
Keith-Wagener-Barker Classification

Keith-Wagener-Barker Classification
Grade 1
Mild narrowing of the arterioles
Copper Wire

Grade 2
Moderate narrowing Copper wire and AV nicking

Changes associated with long standing

essential hypertension

Normal

Grade 1

Keith-Wagener-Barker Classification
Grade 3
Severe Narrowing Silver wire changes, hemorrhage, cotton
wool spots, hard exudates

Grade 4
Grade 3 + Papilledema

Grade 3 and 4 highly correlated with

progression to end organ damage and
decreased survival

Grade 3 KWB Retinopathy

Lab Testing
ECG
LVH, look for signs of ischemia, injury, infarct

Renal Function Tests (urine included)

Elevated BUN, Creatinine, proteinuria, hematuria

CBC
CXR - pulmonary edema, aortic arch, cardiac
enlargement

Lab Testing
Aortic Dissection?
Suspect with severe tearing chest pain,
unequal pulses, widened mediastinum
Contrast Chest CT Scan or MRI

Pulmonary Edema/CHF
Transthoracic Echocardiogram
Differentiate between systolic dysfunction,
diastolic dysfunction, mitral regurgitation

Management
Elevated BP without target organ
damage
Hypertensive urgency
Oral meds
Goal - gradual reduction of BP over 24 48 hours

Management

Elevated BP with target organ damage

Hypertensive emergency
Parenteral meds
Goal - Reduce diastolic BP by 10-15%
or to 110 mm Hg over a period of 30 60 minutes

How Quickly?
Cerebral Blood Flow Autoregulation
Cerebral Blood constant in normotensive
individuals over range of MAPs of 60 -120
mm Hg.
In chronically hypertensive patients
autoregulatory range is higher
MAP Range 100-120 to 150-160 mm Hg

Autoregulation also impaired in the

elderly and those with cerebrovascular
disease

How Quickly?
General rule is to lower MAP by 20% in
first hour
Should always be done with close
clinical observation

Management
Where?
ICU with close monitoring
Severe requires intra-arterial BP monitoring

Which Parenteral meds?

Depends on the situation

Question 4

Which of the following drugs should not

be used to treat hypertensive
emergency?
1.
2.
3.
4.
5.

Sublingual Nifedipine
Labetolol
ACE Inhibitors
Nicardipine
1 and 3

Which of the following drugs should

not be used to treat hypertensive
emergency?
1. Sublingual
Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3

Preferred Agents
Beta blockers
Labetolol
Esmolol

Calcium Entry blocker

Nicardipine

Dopamine-1 receptor agonist

Fenoldapam

Vasodilators - nitroprusside/nitroglucerin

Scenarios
Our Case - Acute ischemic
stroke/cerebrovascular bleed
Agents
Fenoldopam
Labetolol
Nicardipine

CVA or Ischemic Stroke

BP elevation after CVA or ischemic stroke can
be protective to preserve cerebral perfusion
Hold on aggressive lowering unless
Thrombolytic therapy anticipated or
BP excessively high ( SBP > 220 mm Hg or DBP
>120)

BP Goal for thrombolytic therapy is to lower

SBP if > 185 or DBP >110

Cardiac Conditions
Acute Pulmonary Edema with systolic
dysfunction
Nicardipine
Fenoldopam
Sodium nitroprusside
Nitroglycerin
Loop diuretic

Cardiac Conditions
Acute Pulmonary Edema with diastolic
dysfunction
Esmolol, metoprolol, labetolol
verapamil
Nitroglycerin
Loop diuretic

Cardiac Conditions
Acute myocardial ischemia
Esmolol, labetolol
Nitroglycerin

Sympathetic Crisis
Generally in association with
recreational drugs such as cocaine,
amphetamine or phencyclidine
Sudden cessation of clonidine or Betaadrenergic antagonist
Pheochromocytoma - rare

Question 5

Which of the following drugs should be

avoided in sympathetic crises with
hypertensive emergency?
1.
2.
3.
4.
5.

Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam

Which of the following drugs should

be avoided in sympathetic crises with
hypertensive emergency?
1.
2.
3.
4.
5.

Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam

Sympathetic Crisis
Beta-adrenergic antagonists will result
in unopposed alpha-adrenergic
stimulation
In cocaine use, Beta blockers can
Increase blood pressure
Worsen coronary artery vasoconstriction
Decrease survival

Avoid beta blockade (including non

selective agents such as labetolol)

Sympathetic Crisis
Recommended Drugs
Nicardipine
Fenoldopam
Verapamil
Benzodiazepine
If pheo suspected use phentolamine

Aortic Dissection
Treatment is paramount
75% of patients with ascending aortic
dissection die in 2 weeks of the acute
episode without successful therapy
5 year survival is 75% with successful
intervention
Khan et al. Chest 2002, 122:311
Kouchoukos New Engl J Med 1997; 336:1876

Aortic Dissection
Vasodilator alone?
Causes reflex tachycardia
Increases cardiac ejection velocity
Increases aortic shear forces
Extends the dissection

Aortic Dissection
Standard therapy
Beta-adrenergic blocker plus vasodilator
Esmolol + Nicardipine or fenoldopam

Nitroprusside can be used as well

Acute Post Operative Hypertension

Frequent in post-operative state (2075%)
Hyper-responsiveness to surgical
trauma
Increased stress hormones?
Activation of RAA?

Also hypothermia, hypoxia, carbon

dioxide retention, bladder distention

Acute Post Operative Hypertension

Prevention
Safe to give antihypertensives pre-op
Hold diuretics

Treatment - BP thresholds vary

Control pain and anxiety
While NPO use nicardipine, esmolol or
labetolol
Resume oral medications when possible

What happened to sodium nitroprusside?

Mansoor and Friedman. Heart Disease
2002; 4:358
Sodium nitroprusside recommended for all
hypertensive emergencies except
eclampsia

Marik and Varon. Chest 2007; 131:1949

Sodium nitroprusside recommended for
acute aortic dissection
acute pulmonary edema with systolic
dysfunction

riding the pride

Disadvantages of sodium nitroprusside
Decrease cerebral blood flow and increases
intracranial pressure
Can reduce regional blood flow in coronary artery
disease
Risk of cyanide toxicity

Use when other agents not effective

Monitor thiocyanate levels
Avoid in renal or hepatic dysfunction

Have we made progress?

First described by Volhard and Fahr
Die Brightsche Nierenkrankenheit: Klinik
Patholgie und Atlas. Berlin, Germany,
Springer 1914:247

Keith, Wagener, Barker Am J Med Sci,

1939;197:332
Mean survival of patients with htn and
grade 4 retinopathy was 10.5 mo with none
living beyond 5 years

We have made progress

Development of antihypertensive drugs

Increased diagnosis of hypertension
Increased ICU settings
Survival of patients with hypertensive
urgency and emergency is 18 years
compared to 21 years in those with
uncomplicated hypertension

Thank you!
Questions?

When you hear hoof beats

Messerli N Engl J Med 1995;3321038.

Messerli N Engl J Med 1995;3321038.